Case Reports
Case Report -01
A 40 years old male was admitted with a history of fall from 30 feet height about half an hour ago. On initial assessment, his airway was clear with shallow breathing and his GCS was 4/15. His circulation maintained with PR 95/min and SBP 90mmHg. He did not have external bleeding and his all-peripheral pulses were able to feel. Initial FAST scan was negative finding without free fluid in the abdomen. Bleeding from the ears and urethral meatus was observed. Bilateral pupils were non-reactive to light and their size was pinpoint.
He was intubated for mechanical ventilation.
Chest X-Ray revealed multiple rib fractures in both sides without hemo-pneumothorax.
Pelvic X-Ray revealed unstable displaced pelvic fracture. Pelvic fracture was managed by pelvic binder.
Non-contrast brain CT revealed traumatic SAH without midline shift. Head injury was conservatively managed with HIOC and IV Tranexamic acid according to advice of the neurosurgical team.
Because his systolic blood pressure was persistently maintained in low level around 90mmHg despite blood/fluid resuscitation, CECT abdomen and pelvis was planned to find out whether active pelvic bleeding point. But he rapidly deteriorated despite full resuscitation measures deployed and he passed away.
Discussion
Management of multi-trauma patients involves several specialties like surgeon, interventional radiologist transfusion medicine etc. with highly sophisticated relevant infrastructures to achieve the successful outcome.
Surgical intervention to the retroperitoneal pelvic hematoma (particularly in the case of no free fluid in the peritoneal cavity -that means peritoneal tamponade effect is maintained) will further deteriorate the clinical condition. Find the active bleeding with contrast images and follow with interventional radiological therapy will be a better option than open surgery. Best place is in the Hybrid operating room. Any form of intervention needs its own level of clinical stability before intervention, so resuscitation is crucial to achieve the level of clinical stability before any intervention.
but resuscitation is far more important in the management of a multi-trauma patient.
The hybrid operating room is a great advance in the field of surgery to manage this type of cases. It is a surgical room that is equipped with advanced medical imaging/radiodiagnosis devices, allowing different diagnostic and therapeutic procedures to be carried out simultaneously. it allows multidisciplinary work by specialists from different areas and helps to perform complex surgeries faster, easier, safer and less invasively.
Case reviwed by Dr J Gunatheepan MBBS MD MRCS FMAS
Consultant Surgeon – Accident & Orthopedic Service, National Hospital of Sri Lanka